{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,4]],"date-time":"2026-11-04T05:48:38Z","timestamp":1793771318195,"version":"4.6.1"},"reference-count":39,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T00:00:00Z","timestamp":1786924800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med. Technol."],"abstract":"<jats:p>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\u2013response 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.<\/jats:p>","DOI":"10.3389\/fmedt.2026.1845958","type":"journal-article","created":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T05:25:14Z","timestamp":1786944314000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Dissecting and stimulating instruments in thyroid surgery: principles, applications and clinical role"],"prefix":"10.3389","volume":"8","author":[{"given":"Francesco","family":"Brucchi","sequence":"first","affiliation":[{"name":"Division of General Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano","place":["Milan, Italy"]},{"name":"Department of Pathophysiology and Transplantation, University of Milan","place":["Milan, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carla","family":"Colombo","sequence":"additional","affiliation":[{"name":"Department of Pathophysiology and Transplantation, University of Milan","place":["Milan, Italy"]},{"name":"Division of Endocrinology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano","place":["Milan, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Mercante","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology-Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna","place":["Bologna, Italy"]},{"name":"Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum-Universit\u00e0 di Bologna","place":["Bologna, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paolo","family":"Battaglia","sequence":"additional","affiliation":[{"name":"Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, ASST Lariana","place":["Como, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pietro","family":"Indelicato","sequence":"additional","affiliation":[{"name":"Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, ASST Lariana","place":["Como, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diego","family":"Barbieri","sequence":"additional","affiliation":[{"name":"Division of Head and Neck, San Raffaele Scientific Institute IRCCS (Istituto Di Ricovero E Cura a Carattere Scientifico), Otorhinolaryngology Unit","place":["Milan, Italy"]},{"name":"School of Medicine, Vita-Salute San Raffaele University","place":["Milan, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Davide","family":"Lombardi","sequence":"additional","affiliation":[{"name":"Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiologic Sciences and Public Health, University of Brescia","place":["Brescia, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gabriele","family":"Materazzi","sequence":"additional","affiliation":[{"name":"Department of Surgical, Medical, Molecular Pathology and Critical Area, Unit of Endocrine Surgery, Pisa University Hospital","place":["Pisa, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gianlorenzo","family":"Dionigi","sequence":"additional","affiliation":[{"name":"Division of General Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Auxologico Italiano","place":["Milan, Italy"]},{"name":"Department of Pathophysiology and Transplantation, University of Milan","place":["Milan, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,8,17]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1122","DOI":"10.1001\/jamaoto.2017.1746","article-title":"Nationwide variation in rates of thyroidectomy among US medicare beneficiaries.","volume":"143","author":"Francis","year":"2017","journal-title":"JAMA Otolaryngol Head Neck Surg"},{"key":"B2","doi-asserted-by":"publisher","first-page":"1335","DOI":"10.1007\/s002680010221","article-title":"Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany","volume":"24","author":"Thomusch","year":"2000","journal-title":"World J Surg"},{"key":"B3","doi-asserted-by":"publisher","first-page":"663","DOI":"10.1007\/s00423-017-1580-y","article-title":"The current state of intermittent intraoperative neural monitoring for prevention of recurrent laryngeal nerve injury during thyroidectomy: a PRISMA-compliant systematic review of overlapping meta-analyses","volume":"402","author":"Henry","year":"2017","journal-title":"Langenbecks Arch Surg"},{"key":"B4","doi-asserted-by":"publisher","first-page":"765","DOI":"10.1016\/j.jamcollsurg.2014.04.013","article-title":"Examining national outcomes after thyroidectomy with nerve monitoring","volume":"219","author":"Chung","year":"2014","journal-title":"J Am Coll Surg"},{"key":"B5","doi-asserted-by":"publisher","first-page":"819","DOI":"10.1007\/BF03350349","article-title":"Why monitor the recurrent laryngeal nerve in thyroid surgery?","volume":"33","author":"Dionigi","year":"2010","journal-title":"J Endocrinol Invest"},{"key":"B6","doi-asserted-by":"publisher","first-page":"S44","DOI":"10.1016\/S1743-9191(13)60014-X","article-title":"Continuous monitoring of the recurrent laryngeal nerve in thyroid surgery: a critical appraisal","volume":"11","author":"Dionigi","year":"2013","journal-title":"Int J Surg"},{"key":"B7","doi-asserted-by":"publisher","first-page":"e1","DOI":"10.1097\/SLA.0b013e318294559d","article-title":"Limits of neuromonitoring in thyroid surgery","volume":"258","author":"Dionigi","year":"2013","journal-title":"Ann Surg"},{"key":"B8","doi-asserted-by":"publisher","first-page":"566","DOI":"10.1002\/bjs.11901","article-title":"Superiority of continuous over intermittent intraoperative nerve monitoring in preventing vocal cord palsy","volume":"108","author":"Schneider","year":"2021","journal-title":"Br J Surg"},{"key":"B9","doi-asserted-by":"publisher","first-page":"709","DOI":"10.1097\/SLA.0000000000006872","article-title":"Clinical validation of NerveTrend versus NerveAssure mode of intraoperative neuromonitoring in prevention of recurrent laryngeal nerve injury during thyroid surgery: a randomized controlled trial","volume":"282","author":"Barczy\u0144ski","year":"2025","journal-title":"Ann Surg"},{"key":"B10","doi-asserted-by":"publisher","first-page":"2832","DOI":"10.1002\/lary.25251","article-title":"Stimulating dissecting instruments during neuromonitoring of RLN in thyroid surgery","volume":"125","author":"Chiang","year":"2015","journal-title":"Laryngoscope"},{"key":"B11","doi-asserted-by":"publisher","first-page":"996","DOI":"10.1007\/s00464-019-06936-2","article-title":"Stimulating and dissecting instrument for transoral endoscopic thyroidectomy: proof of concept investigation","volume":"34","author":"Zhang","year":"2020","journal-title":"Surg Endosc"},{"key":"B12","doi-asserted-by":"publisher","first-page":"5280939","DOI":"10.1155\/2020\/5280939","article-title":"Feasibility of attachable ring stimulator for intraoperative neuromonitoring during thyroid surgery","volume":"2020","author":"Kim","year":"2020","journal-title":"Int J Endocrinol"},{"key":"B13","doi-asserted-by":"publisher","first-page":"5898","DOI":"10.1038\/s41598-021-84988-y","article-title":"Tensile strength analysis of automatic periodic stimulation for continuous intraoperative neural monitoring in a piglet model","volume":"11","author":"Wang","year":"2021","journal-title":"Sci Rep"},{"key":"B14","doi-asserted-by":"publisher","first-page":"525","DOI":"10.1002\/lary.27327","article-title":"Prediction of postoperative vocal fold function after intraoperative recovery of loss of signal","volume":"129","author":"Schneider","year":"2019","journal-title":"Laryngoscope"},{"key":"B15","doi-asserted-by":"publisher","first-page":"1260","DOI":"10.1002\/lary.25807","article-title":"Prospective study of vocal fold function after loss of the neuromonitoring signal in thyroid surgery: the international neural monitoring study group\u2019s POLT study","volume":"126","author":"Schneider","year":"2016","journal-title":"Laryngoscope"},{"key":"B16","doi-asserted-by":"publisher","first-page":"101285","DOI":"10.1016\/j.beem.2019.06.001","article-title":"Impact of continuous intraoperative vagus stimulation on intraoperative decision making in favor of or against bilateral surgery in benign goiter","volume":"33","author":"Schneider","year":"2019","journal-title":"Best Pract Res Clin Endocrinol Metab"},{"key":"B17","doi-asserted-by":"publisher","first-page":"323","DOI":"10.1186\/s12885-016-2348-4","article-title":"Continuous intraoperative monitoring of pelvic autonomic nerves during TME to prevent urogenital and anorectal dysfunction in rectal cancer patients (NEUROS): a randomized controlled trial","volume":"16","author":"Kauff","year":"2016","journal-title":"BMC Cancer"},{"key":"B18","doi-asserted-by":"publisher","first-page":"994","DOI":"10.1016\/j.ejso.2013.06.004","article-title":"Is intraoperative neuromonitoring associated with better functional outcome in patients undergoing open TME? Results of a case-control study","volume":"39","author":"Kneist","year":"2013","journal-title":"Eur J Surg Oncol"},{"key":"B19","doi-asserted-by":"publisher","first-page":"213","DOI":"10.1177\/1553350613496907","article-title":"Laparoscopic neuromapping in pelvic surgery: scopes of application","volume":"21","author":"Kneist","year":"2014","journal-title":"Surg Innov"},{"key":"B20","doi-asserted-by":"publisher","first-page":"302","DOI":"10.1097\/WNP.0000000000000055","article-title":"Pelvic autonomic neuromonitoring: present reality, future prospects","volume":"31","author":"Skinner","year":"2014","journal-title":"J Clin Neurophysiol"},{"key":"B21","doi-asserted-by":"publisher","DOI":"10.1089\/lap.2018.0742","article-title":"A surgical instrument cover for the prevention of thermal injuries during laparoscopic operations","volume":"29","author":"Carrano","year":"2019","journal-title":"J Laparoendosc Adv Surg Tech A"},{"key":"B22","first-page":"26","article-title":"Zastosowanie materia\u0142u izolacyjnego teflon\u2013pladgets firmy genzyme\u2013USA w operacjach konfliktu naczyniowo-nerwowego nerwu tr\u00f3jdzielnego application of the insulating material teflon\u2013pladgets (genzyme-USA) during the microvascular decompression","volume":"35","author":"Andrychowski","year":"2001","journal-title":"Neurol Neurochir Pol"},{"key":"B23","doi-asserted-by":"publisher","first-page":"S1","DOI":"10.1002\/lary.21119","article-title":"Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement","volume":"121","author":"Randolph","year":"2011","journal-title":"Laryngoscope"},{"key":"B24","doi-asserted-by":"publisher","first-page":"S1","DOI":"10.1002\/lary.24301","article-title":"International neural monitoring study group. External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: international neural monitoring study group standards guideline statement","volume":"123","author":"Barczy\u0144ski","year":"2013","journal-title":"Laryngoscope"},{"key":"B25","doi-asserted-by":"publisher","first-page":"S82","DOI":"10.1016\/j.ijsu.2008.12.013","article-title":"Anaesthesia for thyroid surgery: perioperative management","volume":"6","author":"Bacuzzi","year":"2008","journal-title":"Int J Surg"},{"key":"B26","doi-asserted-by":"publisher","first-page":"223","DOI":"10.1007\/s00268-009-0316-8","article-title":"Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation","volume":"34","author":"Chiang","year":"2010","journal-title":"World J Surg"},{"key":"B27","doi-asserted-by":"publisher","first-page":"743","DOI":"10.1016\/j.surg.2008.02.006","article-title":"The mechanism of recurrent laryngeal nerve injury during thyroid surgery\u2013the application of intraoperative neuromonitoring","volume":"143","author":"Chiang","year":"2008","journal-title":"Surgery"},{"key":"B28","doi-asserted-by":"publisher","first-page":"1730","DOI":"10.1089\/thy.2021.0155","article-title":"Varied recurrent laryngeal nerve course is associated with increased risk of nerve dysfunction during thyroidectomy: results of the surgical anatomy of the recurrent laryngeal nerve in thyroid surgery study, an international multicenter prospective anatomic and electrophysiologic study of 1000 monitored nerves at risk from the international neural monitoring study group","volume":"31","author":"Liddy","year":"2021","journal-title":"Thyroid"},{"key":"B29","doi-asserted-by":"publisher","first-page":"A21","DOI":"10.1016\/j.suronc.2018.01.003","article-title":"Laryngeal nerve morbidity in 1.273 central node dissections for thyroid cancer","volume":"27","author":"Liu","year":"2018","journal-title":"Surg Oncol"},{"key":"B30","doi-asserted-by":"publisher","first-page":"2657","DOI":"10.1002\/hed.25391","article-title":"Diagnosis, anatomy, and electromyography profiles of 73 nonrecurrent laryngeal nerves","volume":"40","author":"Wang","year":"2018","journal-title":"Head Neck"},{"key":"B31","doi-asserted-by":"publisher","first-page":"996","DOI":"10.1007\/s00464-008-0098-3","article-title":"Neuromonitoring and video-assisted thyroidectomy: a prospective, randomized case-control evaluation","volume":"23","author":"Dionigi","year":"2009","journal-title":"Surg Endosc"},{"key":"B32","doi-asserted-by":"publisher","first-page":"908","DOI":"10.1089\/lap.2014.0544","article-title":"The efficacy of intraoperative neuromonitoring during robotic thyroidectomy: a prospective, randomized case-control evaluation","volume":"25","author":"Lee","year":"2015","journal-title":"J Laparoendosc Adv Surg Tech A"},{"key":"B33","doi-asserted-by":"publisher","first-page":"e6674","DOI":"10.1097\/MD.0000000000006674","article-title":"Recurrent laryngeal nerve injury after thyroid and parathyroid surgery: incidence and postoperative evolution assessment","volume":"96","author":"Joliat","year":"2017","journal-title":"Medicine (Baltimore)"},{"key":"B34","doi-asserted-by":"publisher","first-page":"1216","DOI":"10.1007\/s00268-004-7638-3","article-title":"Results of video-assisted parathyroidectomy: single institution\u2019s six-year experience","volume":"28","author":"Miccoli","year":"2004","journal-title":"World J Surg"},{"key":"B35","doi-asserted-by":"publisher","first-page":"785","DOI":"10.1007\/s00595-015-1245-9","article-title":"Prospective validation study of cernea classification for predicting EMG alterations of the external branch of the superior laryngeal nerve","volume":"46","author":"Dionigi","year":"2016","journal-title":"Surg Today"},{"key":"B36","doi-asserted-by":"publisher","first-page":"1436","DOI":"10.1002\/lary.29413","article-title":"Superior laryngeal nerve signal attenuation influences voice outcomes in thyroid surgery","volume":"131","author":"Iwata","year":"2021","journal-title":"Laryngoscope"},{"key":"B37","doi-asserted-by":"publisher","first-page":"116","DOI":"10.1007\/s00423-026-04013-6","article-title":"Simulation unlocked: transforming thyroid surgery training through high-fidelity and curriculum-based innovation-a systematic review","volume":"411","author":"Zhang","year":"2026","journal-title":"Langenbecks Arch Surg"},{"key":"B38","doi-asserted-by":"publisher","first-page":"705346","DOI":"10.3389\/fendo.2021.705346","article-title":"Training courses in laryngeal nerve monitoring in thyroid and parathyroid surgery- the INMSG consensus statement","volume":"12","author":"Wu","year":"2021","journal-title":"Front Endocrinol (Lausanne)"},{"key":"B39","doi-asserted-by":"publisher","first-page":"334","DOI":"10.21037\/gs.2018.11.08","article-title":"Cost and training are diffusion patterns limits for neural monitoring in thyroid surgery","volume":"8","author":"Sun","year":"2019","journal-title":"Gland Surg"}],"container-title":["Frontiers in Medical Technology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmedt.2026.1845958\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T05:25:15Z","timestamp":1786944315000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmedt.2026.1845958\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,17]]},"references-count":39,"alternative-id":["10.3389\/fmedt.2026.1845958"],"URL":"https:\/\/doi.org\/10.3389\/fmedt.2026.1845958","relation":{},"ISSN":["2673-3129"],"issn-type":[{"value":"2673-3129","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,17]]},"article-number":"1845958"}}