Carpal tunnel syndrome is the most common compressive neuropathy encountered by hand and upper extremity surgeons. The predominant presentation includes symptomatic paresthesias in the median nerve distribution of the affected hand, frequently causing nocturnal disturbances. Surgical treatment requires division of the transverse carpal ligament, which can be performed through open and endoscopic means. Endoscopic techniques have evolved significantly since they were first introduced in the late 1980s. This manuscript reviews the literature to summarize the current state of carpal tunnel surgery.While endoscopic techniques have demonstrated superior early functional outcomes and a more rapid recovery, there are lingering concerns over the potential for nerve, vessel, and tendon injuries. These concerns have not been validated by the hand surgery literature, which ascribes similar rates of complications for both open and endoscopic surgical approaches. Moreover, patients report greater satisfaction with endoscopic surgical approaches compared with open techniques. In summary, the debate between proponents of open versus endoscopic carpal tunnel surgery continues. While surgeons who employ endoscopic techniques appear to be in the minority, there is a plethora of evidence to suggest that both approaches are comparably safe and equally effective.