Median arcuate ligament syndrome (MALS) is a rare condition that has undergone significant evolution in its diagnosis and treatment since its first surgical description in 1963. This chapter traces the historical progression of MALS etiology, pathophysiology, and treatment modalities, from open surgery to minimally invasive techniques. Pioneering studies by Harjola and Dunbar established the foundational understanding of MALS, focusing on the mechanical compression of the celiac artery. However, recent advancements suggest a neurogenic component, leading to shifts in treatment approaches. This chapter explores the transition from open to laparoscopic and robotic surgery, highlighting the importance of multidisciplinary collaboration in managing this complex condition. Future directions point toward personalized medicine and advanced imaging techniques to further refine MALS treatment.