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.