How I Do It: Posterior Rectus Sheath Flap for Hiatal Augmentation (PoRSHA)

Paraesophageal hernia (PEH) repair remains plagued by high recurrence rates, suggesting that failure reflects a biologic limitation of the hiatal complex rather than purely technical shortcomings. Primary crural closure places significant tension on attenuated, muscle-derived tissue that is poorly suited to withstand chronic physiologic load, predisposing repairs to breakdown. Although prosthetic mesh may provide short-term reinforcement, it introduces well documented morbidity, including erosion, stricture, dysphagia, and the long-term risks of permanent foreign material at the hiatus. To address this fundamental mismatch between tissue biology and repair demands, we developed the posterior rectus sheath flap for hiatal augmentation (PoRSHA), a robotic reconstructive technique that uses a vascularized autologous fascial flap harvested from the posterior rectus sheath and based on the falciform pedicle. The flap is incorporated into the cruroplasty to offload tension, reinforce high-risk regions, and provide durable, living tissue support. By replacing prosthetic reinforcement with vascularized autologous fascia, PoRSHA offers a biologically sound solution with our early results suggesting potential for a more durable solution to complex hiatal hernia repair.