Ultrasound alone is sufficient: no added value of electromyography in botulinum toxin prehabilitation for complex ventral hernias?

INTRODUCTION

The use of botulinum toxin (BT) and progressive pneumoperitoneum (PPP) as a prehabilitation strategy for complex ventral hernias has gained widespread acceptance. While ultrasound (US) is the standard method for guiding BT infiltration, the added value of electromyography (EMG) remains unclear.

OBJECTIVES

To evaluate the radiologic effectiveness of abdominal wall prehabilitation using BT infiltration guided by US alone compared to US combined with EMG. MATERIALS AND

METHODS

A single-center, observational, prospective, and analytical study was conducted between January 2019 and March 2025. Patients undergoing surgery for primary or incisional ventral hernia who received BT + PPP prehabilitation were included. Patients without post-prehabilitation follow-up CT scans and those with lateral, parastomal, or combined midline-lateral incisional hernias were excluded. Demographic, clinical, hernia-related, and abdominal wall conditioning variables were collected. Data analysis was performed using IBM® SPSS® with appropriate statistical tests.

RESULTS

A total of 46 patients were included. Both groups showed significant elongation and thinning of the lateral abdominal wall musculature after BT + PPP (p < 0.001). No significant differences were observed between the US + EMG group and the US-only group in terms of muscle elongation (4 [3.4–5.9] cm vs. 4.3 [2.9–6.2] cm; p = 0.965) or muscle thinning (1.02 [0.55–1.77] cm vs. 1.3 [0.83–1.85] cm; p = 0.515). No differences were found in transverse hernia diameter reduction or PPP volume administration between groups.

CONCLUSION

US-guided botulinum toxin injection is as effective as the technique combining US with EMG. Our findings indicate that the incorporation of EMG does not confer any additional radiologic benefit. However, further studies are needed to corroborate these findings.