Background and Aims The application of robotic systems in thyroid surgery has gradually expanded, but there is limited large-sample reports on bilateral axillo-breast approach (BABA) thyroidectomy using the 4th-generation da Vinci surgical robot both locally and abroad. Therefore, this study was performed to summarize the treatment outcomes and experiences of BABA thyroidectomy cases completed at the authors' center using the 4th-generation da Vinci surgical robot, so as to provide reference information for clinical practice.Methods The clinical data of 649 patients undergoing the 4th-generation da Vinci robot-assisted BABA thyroidectomy at the Department of Thyroid Surgery of China-Japan Union Hospital of Jilin University from April 2020 to August 2023 were retrospectively collected. Relevant clinical variables were summarized and analyzed.Results Of the 649 patients, 79 were males and 570 were females, with an age range of 13 to 64 years and an average age of (35.1±9.2) years. There were 464 cases of unilateral malignancy, 107 cases of bilateral malignancy, 64 cases of unilateral benign tumors, and 14 cases of bilateral benign tumors. All surgeries were successfully completed without conversion to open surgery, with a median operative time of 130 (110-150) min. In 571 cases of malignant lesions, the total number of central lymph nodes (CLNs) dissected was 2 628, with an average of number of 4.60±3.59; the total number of positive CLNs was 489 (18.6%), with an average of number of 0.86±1.65. On the third postoperative day, the proportions of painless and mild, moderate, and severe pain were 52.2%, 30.5%, 17.3%, and 0, respectively. The median postoperative hospital stay was 3 (3-3) d, and the median hospitalization cost was 50 500 (48 100-56 700) yuan. During operation, EMG signal degradation of the recurrent laryngeal nerve (RLN) occurred in 71 cases. After operation, temporary RLN injury occurred in 17 cases; temporary coughing during drinking occurred in 4 cases, and temporary reduction of vocal range occurred in 10 cases; temporary hypocalcemia occurred in 145 cases. During a median follow-up of 6 months, the overall satisfaction rate was 94.6%, with no permanent complications. Learning curve analysis showed a significant decrease in the curve at the 26th case, followed by stabilization, and similar learning curves were observed between different surgical procedures.Conclusion The 4th-generation da Vinci robot-assisted BABA thyroidectomy is safe, effective, and offers good minimally invasive cosmetic results. Adherence to a learning curve is necessary during the application process, and the mastery of the robotic surgical operating system is a key factor influencing the surgical process.