Material and Methods: A retrospective analysis of 41 consecutive patients who underwent robotic-assisted thoracic surgery (RATS) for mediastinal lesions between December 2023 and December 2025 was conducted. Procedures included lateral decubitus and subxiphoid approaches. To mitigate variations in case complexity, an Observed-Expected (O-E) approach-adjusted Cumulative Sum (CUSUM) model was employed for both access/docking time (operating room team adaptation) and console time (procedural adaptation). Phase 1
Results: The mean age was 44.8 ±13.4 years. The approach-adjusted console time CUSUM demonstrated an inflection point at case 16, whereas the access/docking time CUSUM reached inflection at case 24. Comparing Phase 1 (n = 16) and Phase 2 (n = 25), the median O-E console time deviation showed a trend toward improvement from +10.0 to -13.9 minutes (p = 0.219), despite an increased proportion of technically demanding subxiphoid cases in Phase 2. Estimated blood loss significantly decreased in Phase 2 (0.0 mL vs. 10.0 mL, p = 0.025). The safety profile remained high, with no conversions in the learning phase, low postoperative complications (n = 2 vs. n = 2), and zero mortality.
Conclusions: The implementation of a newly established robotic mediastinal surgery program demonstrates feasibility with acceptable short-term outcomes when preceded by structured training. A dual-axis approachadjusted CUSUM analysis suggests that procedural proficiency and team adaptation occur at different phases,
