Dissecting and stimulating instruments in thyroid surgery: principles, applications and clinical role

Stimulating dissecting instruments (SDIs) combine fine dissection and calibrated nerve stimulation in a single tool, addressing the workflow limitations of conventional intermittent intraoperative neuromonitoring (IONM) in thyroid and parathyroid surgery. By eliminating repeated exchanges between a dissecting instrument and a separate stimulator, SDIs enable quasi-continuous functional assessment of the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN) precisely during high-risk maneuvers, such as Berry's ligament dissection and superior pole management. Prospective clinical data in open thyroidectomy show that SDIs are feasible, safe, and effective in detecting early traction-related EMG changes, allowing timely release of stress and resulting in very low rates of postoperative RLN palsy, while experimental endoscopic and transoral models confirm reliable dose–response characteristics at clinically acceptable stimulation thresholds. In minimally invasive and narrow-corridor approaches, SDIs reduce instrument traffic and maintain neuromonitoring without disrupting operative flow, and their real-time feedback enhances training by directly linking dissection quality to neurophysiological signals. Within current guideline-based IONM frameworks, SDIs represent a practical evolution toward integrated, high-frequency monitoring, with future development expected to focus on their combination with energy-based devices, advanced imaging, and intelligent EMG analysis.