IDEAL Phase 2a Results: Posterior Rectus Sheath Flap for Hiatal Augmentation in Complex Paraesophageal Hernias.

Abstract

To report the developmental phase results of posterior rectus sheath hiatal flap augmentation (PoRSHA), a promising surgical innovation for large and recurrent paraesophageal hernias. Durable hernia repair for large paraesophageal hernias continues to be a surgical challenge. PoRSHA addresses the challenges of current and historical approaches to complex paraesophageal hernias and demonstrates significant promise as a successful alternative approach. Using the IDEAL framework, we outline the technical modifications made over the first 27 consecutive cases using PoRSHA. Outcomes measured included hernia recurrence on routine imaging at 6 months and 2 years, development of a postoperative abdominal wall eventration and incidence of solid food dysphagia. Twenty-seven patients at our single institution with type III (n=12), type IV (n=7) or recurrent (n=8) paraesophageal hernias underwent PoRSHA. Surgery was safely and successfully carried out in all cases. Stability of the technique was reached after 16 cases resulting in four main repair types. At an average follow up of 11 months, we observed no radiologic recurrences, no abdominal eventrations or hernias at the donor site and one patient with occasional solid food dysphagia that resolved with dilation. PoRSHA can not only be safely added to conventional hiatal hernia repair with appropriate training, but also demonstrates excellent short-term outcome. While the long-term durability with 5 year follow up is still needed, here we provide cautious optimism that PoRSHA may represent a novel solution to the longstanding high recurrence rates observed with current complex PEH repair.