Importance The use of robotic-assisted groin hernia repair is increasing rapidly across the US, but evidence regarding its comparative effectiveness to more established laparoscopic or open approaches is limited. Objective To compare the incidence of long-term operative hernia recurrence between robotic-assisted, laparoscopic, and open groin hernia repairs. Design, Setting, and Participants This retrospective cohort study analyzed groin hernia repairs among Medicare beneficiaries aged 65 years and older from January 2010 to December 2021, with 5-year follow-up, using a population-based analysis of US inpatient and outpatient administrative claims. Data were analyzed between August 2024 and April 2025. Exposure Surgical approach: robotic-assisted, laparoscopic, or open groin hernia repair. Main Outcomes and Measures The main outcome was operative recurrence up to 5 years after initial groin hernia repair. Cox proportional hazards modeling was used to estimate the risk-adjusted cumulative incidence of operative recurrence up to 5 years after the initial procedure, controlling for patient demographics, comorbidities, hernia type (inguinal or femoral), and procedure type (unilateral or bilateral). Results A total of 199 163 Medicare beneficiaries (mean [SD] age, 72.6 [9.3] years; 29 307 female patients [14.7%]) were included in the study. From January 2010 to December 2021, the proportion of robotic-assisted procedures increased 8.6-fold, from 0.3% to 2.6%. The proportion of open procedures decreased 0.6-fold (84.4% to 51.9%), while laparoscopic procedures increased 3.0-fold (15.3% to 45.5%). Patients undergoing robotic-assisted hernia repair had the highest 5-year risk-adjusted cumulative incidence of operative recurrence (3.78%; 95% CI, 3.76%-3.79%), followed by open (3.37%; 95% CI, 3.36%-3.37%) and laparoscopic (3.21%; 95% CI, 3.21%-3.22%) approaches. Compared to open repairs, the laparoscopic approach was associated with a lower risk of operative recurrence (hazard ratio [HR], 0.75; 95% CI, 0.66-0.86), while there was no difference in risk of operative recurrence between the open and robotic cohorts (HR, 1.29; 95% CI, 0.48-2.10). Conclusions and Relevance In this cohort study among Medicare beneficiaries, robotic-assisted groin hernia repair was associated with a higher long-term cumulative incidence of operative recurrence compared to open and laparoscopic approaches. With low operative recurrence rates across all surgical techniques, these findings suggest that alternative measures of clinical value may be necessary to assess the benefits of minimally invasive approaches, particularly as robotic-assisted repair continues to expand.