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REDEFINING PARAESOPHAGEAL HERNIA REPAIR: MIDTERM OUTCOMES OF THE NOVEL PORSHA TECHNIQUE FOR COMPLEX HIATUS RECONSTRUCTION
Michelle Campbell
*, Yalini Vigneswaran, Mustafa Hussain, Vivek Prachand
Surgery, The University of Chicago, Chicago, IL
Introduction: Paraesophageal hernia (PEH) repair remains one of the most challenging areas in modern foregut surgery. To address this signification limitation, we developed the
posterior rectus sheath flap for hiatal augmentation (PoRSHA) leveraging principles of tissue rearrangement from plastic reconstructive surgery. This study reports the midterm safety and efficacy outcomes of PoRSHA in the first 58 patients treated at our institutional series.
Methods and Procedures: A prospective observational cohort study of consecutive patients who underwent repair with PoRSHA since 2021 is reviewed here. Primary outcomes included perioperative morbidity and hernia recurrence on routine postoperative esophagram. Secondary outcomes assessed symptom resolution and abdominal wall integrity on clinical examinations at 1 month, 6 months, and annual follow up postoperatively.
Results: PoRSHA was successfully performed in 58 patients, including primary repairs (n=41; Type III: 27, Type IV: 13, Sliding: 1) and revisional repairs for recurrent PEH (n=17). The cohort was predominantly female (77.4%), with a mean age of 65.8 years and mean BMI of 28.4 kg/m
2. The overall radiologic recurrence rate for the cohort was 8.1% (3/37) at an average 11.6 months. For primary repairs, the radiologic recurrence rate was 3.8% (1/26) at an average of 10.7 months.
Two radiologic recurrences occurred after revisional operations, and one was after a primary Type III repair. All recurrences were <3cm and managed with medical management only. Major perioperative morbidities included postoperative tension pneumothorax requiring tube thoracostomy (n=2) and pulmonary embolus (n=1). Minor morbidity included postoperative ecchymosis at the flap donor site (n=4). No patients experienced abdominal wall eventration or long-term weakness. Postoperatively, two patients had an umbilical hernia, and one patient had a 2cm epigastric hernia.
Conclusion: The PoRSHA technique offers a safe and effective option for complex hiatus reconstruction in both primary and revisional PEH repairs. Early and midterm results demonstrate low recurrence rates in primary repairs, with rates below those reported for existing mesh and non-mesh techniques. These findings underscore the potential of PoRSHA to redefine the standard of care for large and recurrent PEH repairs, particularly in challenging cases where conventional approaches have fallen short.
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