Vascularized posterior rectus sheath flap (PORSHA) shows promising results for complex paraesophageal hernia repair, with low recurrence rates and minimal donor-site morbidity.

• Radiologic recurrence was 1.4% at 12 months and 13.8% at 24 months, stabilizing at 18.1% through 48 months.
• Excluding the procedural maturation phase, recurrence improved to 9.2% at 24 and 36 months, with no reoperations.

These findings suggest that PORSHA may be a viable option for reducing recurrence in this challenging surgical population.