Robotic Repair of Right-Sided Direct Inguinal, Indirect Inguinal, Femoral, and Obturator Hernias (Quadruple Groin Hernias).

Inguinal, femoral, and obturator hernias are a bulge or protrusion of abdominal contents into the inguinal canal, femoral ring, and obturator ring, respectively. Only a few cases of combined inguinal and femoral or obturator hernias have been reported. Laparoscopic and robotic repair seems safe and feasible in these cases. A 74-year-old male presented with significant pain and a bulge protruding in the right groin reaching into the scrotum. He consented to robotic-assisted inguinal hernia repair.  Eight mm trocars were placed into the umbilicus and to the left and right of it. On exploration, a right pantaloon hernia was visualized. The peritoneal flap was developed from a transverse incision above the hernia. On preperitoneal dissection, in addition, a femoral hernia was found. The contents of all three hernias were reduced, and the sack of the indirect hernia was degloved after the chord was dissected off. The lateral channel was developed in the usual fashion. Whilst developing the medial channel to below the pubic bone, an obturator hernia was found; the contents were reduced. The large medial inguinal hernia defect was closed with a running 3-0 barbed suture. The landing zone was fully developed. A large self-fixating mesh was placed covering all four hernia defects with appropriate overlap in all directions. The patient was discharged within three hours after surgery and had an uneventful recovery.  To the best of our knowledge, this is the first "quadruple" groin hernia repair using the robotic approach. During dissection in laparoscopic/robotic inguinal hernia repair, surgeons should actively look for additional defects.