Introduction: Testicular ischaemia is rare complication following inguinal hernia repair, complicating up to 1 in 200 open repairs. This case describes a unique risk factor for testicular ischaemia following hernia repair and a discussion of other risk factors and techniques to help minimise these. Case: A 50-year-old man represents to Emergency Department day 5 post operatively with left sided scrotal pain, swelling and skin discolouration, following elective Lichtenstein repair of a 20mm left sided indirect inguinal hernia with mesh. Further past surgical history is remarkable for a laparoscopic radical nephrectomy for renal cell carcinoma on the ipsilateral side. Inflammatory makers were raised and doppler ultrasound identified reduced blood flow to the left testicle and surrounding haematoma. The patient proceeded to trans-scrotal orchidectomy the same day. Discussion: Testicular ischaemia following hernia repair is thought to be due to congestion and acute thrombosis of the pampiniform venous plexus, rather than arterial injury, given collateral supply to the testes. The patient had previously undergone left sided nephrectomy, with ligation of the left testicular vein. We suggest this decreased venous drainage predisposed the patient to subsequent ischaemia. No cases were found in the literature of inguinal hernia repair post nephrectomy with or without testicle ischaemia. General suggestions to minimise risk of testicular ischaemia include not dissecting beyond the pubic tubercle, leaving distal indirect hernia sacs and cord lipomas intact, and avoiding concomitant scrotal surgery.