Regardless the general acceptance of cardiac operations by physicians and patients as routine procedures since the early seventies conventional cardiac surgery is still associated with a significant surgical trauma and exceptional invasiveness in part effected by the extracorporeal circulation. In parallel to the common interest of nearly all surgical fields to minimize the invasiveness of surgery the intentions in cardiac surgery aim at minimizing surgical access on the one hand and avoidance of extracorporeal circulation on the other hand. Subsequently a broad variety in applying minimal surgical access including total endoscopic procedures as well as beating heart surgery without extracorporeal circulation with modified cannulation and clamping technology was investigated. Out of these three different concepts were essentially developed for coronary surgery. 1. The MIDCAB (minimally invasive direct coronary artery bypass) procedure with revascularisation of the LAD through an anterior mini-thoracotomy using the left IMA on the beating heart. 2. The OPCAB (off-pump coronary artery bypass) procedure by use of a median complete or partial sternotomy with multi-vessel revascularisation on the beating heart. 3. The TECAB (totally endoscopic coronary artery bypass) procedure with total endoscopic access usually under conditions of extracorporeal circulation. Concluding from significant experience over several years MIDCAB and OPCAB procedures are adequately accepted and can be offered for suitable patients. Regarding the yearly case-load of around 70,000 procedures in coronary surgery in Germany minimally invasive techniques are applied in just up to 4-5%. The individual coronary anatomy and presence of co-morbidities represent essential selection factors deciding over the potential use of minimally invasive techniques.