Obturator hernia is a rare clinical entity that predominantly affects elderly, thin women due to anatomical factors such as a wider pelvis and the loss of preperitoneal fat. Despite its classic description, the preoperative diagnosis remains a major challenge due to its deep location and non-specific presentation as a mechanical small bowel obstruction. This report describes the case of a 66-year-old female whose history of prior abdominal surgeries created a diagnostic bias toward adhesive obstruction, resulting in an initial period of conservative management. The most significant clinical signs were absent, leading to a delay in obtaining advanced imaging. Computed tomography eventually identified a right-sided obturator hernia complicated by intestinal perforation. During emergency laparotomy, fecal peritonitis and a friable ileal loop with multiple perforations were identified, necessitating a significant bowel resection. Due to the gross contamination of the surgical field, the defect was repaired using a primary suture technique to minimize the risk of infection associated with prosthetic materials. The patient's fatal outcome underscores that the prognosis of this condition depends primarily on the timing of the diagnosis and prompt surgical intervention. High clinical suspicion in geriatric patients with intestinal obstruction, even in those with a history of prior surgery, is fundamental to reducing the mortality associated with this condition. The choice of primary repair remains a safe and necessary strategy in the presence of fecal contamination to avoid complex postoperative complications.

BACKGROUND Autosomal dominant polycystic kidney disease (ADPKD) is frequently associated with massive kidney enlargement, which complicates kidney transplantation by limiting intra-abdominal space. Simultaneous bilateral nephrectomy with kidney transplantation can reduce surgical burden and avoid staged procedures, but it is technically demanding and rarely performed using robotic surgery. No such cases have been reported previously in Asian patients. CASE REPORT Two adult patients with end-stage kidney disease due to ADPKD presented with severe abdominal distension, pain, early satiety, and impaired quality of life caused by massively enlarged kidneys extending into the pelvis. Robot-assisted simultaneous bilateral nephrectomy was performed using a transperitoneal approach, followed by living-donor kidney transplantation during the same operation. Despite distorted anatomy, limited working space, and extensive vascular adhesions, robotic nephrectomy allowed precise dissection and safe completion of bilateral kidney removal. After repositioning, graft implantation in the iliac fossa was successfully achieved. Operative times were prolonged (approximately 10 hours and 9 hours), reflecting the complexity of simultaneous bilateral nephrectomy and transplantation, while estimated blood loss remained low and no transfusions were required. Both patients demonstrated immediate graft function, early ambulation, and uneventful recovery without intraoperative or postoperative complications. CONCLUSIONS Robot-assisted simultaneous bilateral nephrectomy with kidney transplantation is feasible and safe in selected patients with severely enlarged polycystic kidneys. These first reported Asian cases suggest that this approach may offer perioperative and recovery advantages while avoiding the risks of staged operations.